Leadership Analysis Strategy for the Prevention of
Catheter Associated Urinary Tract Infections: Foley Free Program Nate Dixon, Amanda Mikula, Mary Nason, Bill Winowiecki, and Sara Young Ferris State University
CAUTI LEADERSHIP ANALYSIS STRATEGY 2 Abstract Catheter associated urinary tract infections (CAUTI) continue to be a problem especially in the acute care setting. Increased length of hospital stay, reduced quality of patient care, and loss of hospital reimbursement are all associated with CAUTI. The Foley-Free program outlines the implementation of a nurse-driven protocol for the prevention of CAUTI through the development of an interdisciplinary team. This nurse-driven strategy illustrates the steps needed to decrease the use of indwelling urinary catheters and thus the incidence of CAUTI, causing improved patient outcomes. Evaluation of these measures reflects evidence-based research and upholds professional nursing standards of care. Keywords: CAUTI, Foley-Free, evidence-based practice, acute care setting, patient outcomes, nurse-driven protocol
CAUTI LEADERSHIP ANALYSIS STRATEGY 3
Leadership Analysis Strategy for the Prevention of Catheter Associated Urinary Tract Infections: Foley Free Program Catheter-associated urinary tract infections (CAUTI) are a common healthcare-associated infection and a major concern for all healthcare workers. They cause an increased amount of pain and discomfort, and lead to increased length of stay, cost, and mortality. Each year, more than 13,000 deaths are associated with CAUTI (CDC, 2012), making it an important focus for nursing interventions. CAUTI is defined as clinical symptoms and laboratory evidence of urinary tract infection in a patient who has had a urethral catheter in place for more than two days (Magers, 2013). In addition, reimbursement from Medicare and Medicaid is dependent upon the absence of CAUTI. Catheter Associated Urinary Tract Infection Prevention Approximately 75% of urinary tract infections (UTI) acquired while in the hospital are associated with urinary catheter use (CDC, 2012). The most significant risk factor for developing a UTI is prolonged use of indwelling urinary catheters (CDC, 2012). CAUTI can lead to complications such as cystitis, pyelonephritis, gram-negative bacteremia, prostatitis, epididymitis, orchitis, endocarditis, vertebral osteomyelitis, septic arthritis, endophthalmitis, and meningitis (CDC, 2012). CAUTI is the most common hospital acquired infection (HAI) (CDC, 2012). Beginning in 2008, the Centers for Medicare and Medicaid Services (CMS) stopped reimbursing hospitals for treatments specific to reasonably preventable hospital acquired complications. The intention was to encourage hospitals to improve patient safety in addition to reducing Medicare spending. CAUTIs are considered reasonably preventable and as such, no additional payment is provided to hospitals for CAUTI-related treatment. Hospitals are required CAUTI LEADERSHIP ANALYSIS STRATEGY 4 to report certain data about patients at the time of discharge (administrative discharge claims data). This data can then be used to deny payment for specific complications (HAIs) in addition to publicly reporting and comparing hospitals using their complication rates (Meddings et al., 2012). Fortunately, the use of Foley-Free programs with nurse-driven protocols in acute-care settings have been shown to significantly reduce catheter use and thus CAUTI (Mori, 2014). Interdisciplinary Team An interdisciplinary team is a group of healthcare workers that comes together with the common goal to collaborate and improve patient health and well being (Yoder-Wise, 2011). Utilization of an interdisciplinary team is crucial for the implementation of a Foley-Free program. A team approach is necessary for creating an evidence-based nurse-driven protocol, obtaining electronic data about the use of urinary catheters, determining dwell times and prevalence rates of CAUTI, and evaluating outcomes and data after protocol initiation. This interdisciplinary team is also responsible for hospital-wide education for the prevention of CAUTI. It will consist of floor nurses, a charge nurse, a physician liaison, a quality improvement representative, education services, a pharmacist, and an infectious disease physician. Since nursing is at the frontline of catheter care, this protocol will be nurse-driven and the team will be nurse-led. The floor nurses will communicate the presence of an indwelling urinary catheter at the end of each shift to the charge nurse and provide the reason for the continued need for the catheter. The charge nurse will maintain a list of those on the unit with catheters as well as insertion dates and reason for continued need. This list, in addition to the electronic medical record, will provide data for quality improvement personnel to track the number of catheters is use, reason for use, indwelling times, infection rates, and signs of active infection. If a CAUTI is CAUTI LEADERSHIP ANALYSIS STRATEGY 5 suspected, the primary care provider, infectious disease doctor, and pharmacist will be notified and further treatment discussed. Education staff will be responsible for maintaining evidence- based protocols and ensuring that staff is educated and updated regarding any changes to the protocol. Data Collection Method The collection of data is an important aspect in determining the incidence of CAUTI. Quality improvement utilizes collected data to initiate changes in the protocol or provide education where gaps in communication or skills are noticed. A study by Magers (2013), utilized statistical software to collect data on the number of days a catheter was in place before and after nurse-driven protocols were initiated in addition to collecting data on CAUTI rates. Use of a computer program that is embedded within the nursing assessment that asks specific questions regarding catheter use, insertion date, removal date, and reason for use can be utilized by quality improvement to track data and trends. Additionally, the Agency for Healthcare Research and Quality has funded the On the CUSP: Stop CAUTI initiative that provides data- collection support for organizations striving to reduce CAUTI (AHRQ, 2014). The Foley-Free program plans to utilize both forms of data collection to track trends in catheter use, CAUTI rates, and to guide infection prevention efforts based on evidence-based nursing research. Outcomes for CAUTI Initiatives Outcomes in the prevention of CAUTI include indications for catheter use, documentation, communication, and compliance each shift. Staff education and competency will be provided and monitored twice a year to review the protocol and changes to policy. The goal of the Foley Free program is to reduce the number of patients who receive indwelling catheters by 25% in 90 days. For patients who meet the criteria for indwelling catheters, the goal is to CAUTI LEADERSHIP ANALYSIS STRATEGY 6 reduce the number of dwelling days by 25% in 90 days. Multiple studies indicate that 21-56% of urinary catheters are placed without appropriate indication (Meddings et al., 2014). The CDC recommends catheter use only for: peri-operative for selected surgical procedures (with removal within 24 hours), urine output monitoring in critically ill patients, management of urinary retention or obstruction, assistance in pressure ulcer healing for those who are incontinent, end- of-life care, or prolonged immobilization (Mori, 2014). Adherence to the recommended CDC guidelines will be included in the Foley Free protocol, which will improve outcomes associated with CAUTI. Implementation Strategies Evidence extensively studied by the CDCs Healthcare Infection Control Practices Advisory Committee (HICPAC) and CMS strongly supports core strategies in the reduction of CAUTIs (Magers, 2013). These basic strategies include the practice of good hygiene, use of standard precautions, aseptic technique during catheter placement, use of high quality sterile equipment, maintenance of a closed drainage system, unobstructed flow, and ensure drainage bag remains below the level of the bladder (Magers, 2013). Making sure these basic core strategies are implemented involves educating staff, team building, and encouragement for successful outcomes. In-services will be held initially for all staff to review evidence-based guidelines and a short quiz will administered. Nursing will be the driving force behind the administration of the Foley-Free program. Huddles at shift change led by the charge nurse will alert all staff of patients with catheters and keep the focus on the importance of reducing CAUTI. Nursing documentation in the electronic medical record will include a checklist explaining reasons for indwelling catheter use. If a catheter is not indicated by one of the outlined reasons, it will be the nurses responsibility to CAUTI LEADERSHIP ANALYSIS STRATEGY 7 notify the primary care doctor. If a catheter is indicated, use of a securement device will be utilized to reduce bacterial contamination and irritation in addition to the recommended core strategies outlined in the protocol. Quality improvement will track catheter use and CAUTI and quarterly meetings with staff will display results of protocol adherence. Nursing is responsible for initial placement and daily maintenance of catheters and therefore is ideally positioned in the healthcare setting to initiate and execute protocols for catheter use and CAUTI prevention. According to a study by Mori (2014), catheter usage was reduced to 27.7% from 37.6% and CAUTI rate was reduced from 0.77% to 0.35% utilizing nurse-driven protocols. This demonstrates higher quality of care and improved outcomes for hospitalized patients. Evaluation Hospitals are required to report instances of CAUTI monthly (Gould, Umscheid, Agarwal, Kuntz, & Pegues, 2009). They must also follow the National Healthcare Safety Network (NHSN) CAUTI protocol exactly and report complete and accurate data in a timely manner. Nurse-driven quality improvement projects related to CAUTI must include a detailed evaluation process such as the Plan-Do-Study-Act (PDSA) guidelines recommended by the Agency for Healthcare Research and Quality (AHRQ). This cycle is a checklist and scientific method used for action-oriented learning that plans the observation or data collection, does or tests the action on a small scale, studies or analyzes data and results, and acts or refines changes needed in the program (AHRQ, 2014). Using a retrospective chart review, prevalence of catheter usage and dwell time will be measured three months before and three months after implementation of the nurse-driven Foley- Free protocol. Data will be collected using computerized patient records and databases to retrieve patient demographic information, admitting diagnosis, age, and sex. Indwelling catheter CAUTI LEADERSHIP ANALYSIS STRATEGY 8 usage will be tabulated monthly from nursing clinical documentation. The sum of catheter days will be divided by the total patient days and multiplied by 100 for a percentage of catheter usage for each month (Mori, 2014). Unit specific CAUTI rates will be offered quarterly to nursing and other clinical staff. Participating units will be requested to complete a Foley Free protocol assessment evaluating three primary areas: adoption of Foley Free activities, implementation of CAUTI reduction steps, and protocol barriers. The purpose of this tool is to keep patient safety the primary focus at both the system and unit level (Gould et al., 2009). Conclusion Healthcare-associated infections are a significant cause of illness, death, and excessive costs in all health care settings (Gould et al., 2009). Findings support the use of nurse-driven quality improvement projects and protocols to decrease the incidence of CAUTI, and to improve the quality of care for hospitalized patients (Mori, 2014). Use of interdisciplinary teams along with a team building culture that strives for reduction in CAUTI as well as use of data collection to drive improvements in protocol will reveal positive patient outcomes and reduce length of stay in acute care settings. Essentially, the best scientific evidence should be the foundation of all patient care and should not vary from clinician to clinician. CAUTI LEADERSHIP ANALYSIS STRATEGY 9 References Agency for Healthcare Research and Quality (AHRQ). (2014). Plan-do-study-act (PDSA) cycle. Retrieved from http://www.innovations.ahrq.gov/content.aspx?id=2398 Centers for Disease Control and Prevention (CDC). (2012). Catheter-associated urinary tract infections (CAUTI). Retrieved from: http://www.cdc.gov/HAI/ca_uti/uti.html Gould, C.V., Umscheid, C.A., Agarwal, R.K., Kuntz, G., & Pegues, D.A. (2009). Healthcare infection control practices advisory committee: Guideline for prevention of catheter- associated urinary tract infections. Atlanta, GA: Centers for Disease Control and Prevention. Magers, T. (2013). Using evidence-based practice to reduce catheter-associated urinary tract infections. American Journal of Nursing, 113, 34-42. Meddings, J., Reichert, H., Rogers, M., Saint, S., Stephansky, J., & McMahon, L. (2012). Impact of non-payment for hospital-acquired catheter-associated urinary tract infection: A statewide analysis. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3652618 Meddings, J., Rogers, M., Krein, S.L., Fakih, M.G., Olmstead, R., & Saint, S. (2014). Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: An integrative review. British Medical Journal Quality & Safety, 23, 277-289. doi:10.1136/bmjqs-2012-001774 Mori, C. (2014). A-voiding catastrophe: Implementing a nurse-driven protocol. MEDSURG Nursing, 23, 15-28. Yoder-Wise, P. S. (2011). Leading and managing in nursing (5 th ed.). St. Louis, MO: Elsevier Mosby.